Affidavit Of Domestic Partnership - Maryland

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Affidavit of Domestic Partnership
We, _________________________________________ and ______________________________________ certify that:
(Print name of State of Maryland Employee/Retiree)
(Print name of Domestic Partner)
1. We are the same sex.
2. We are not legally married to, in a civil union with, or in a domestic partnership with anyone else.
3. We are eighteen (18) years of age or older.
4. We are not related by blood closer than would bar marriage in the State of Maryland.
5. We are in a committed relationship and intend to remain so indefinitely and are emotionally and financially responsible for our
common welfare.
6. We have been financially interdependent for at least twelve (12) consecutive months.
7. We share a common primary residence.
8. We agree that domestic partners are subject to the same terms and conditions governing all other employees who are covered by or
are applying for benefits.
9. Employee/Retiree agrees to notify the State of Maryland within sixty (60) days of the dissolution of our domestic partnership on the
form provided by the State for that purpose. Employee/retiree agrees to provide a copy of the form to the other partner.
10. We agree to notify the State of Maryland within sixty (60) days of any change in the dependent status of the domestic partner or the
children of the domestic partner.
11. We understand that the information contained in this Affidavit of Domestic Partnership will be maintained as confidential, but may
be disclosed in response to a court order, subpoena, or public records request. We understand that the State will need to share
information with the State benefit plan administrators and third parties with whom the State contracts for benefit programs.
12. We affirm, under penalties of perjury, that the statements in this Affidavit of Domestic partnership are true.
____________________________________
____________________________________
Signature of Employee/Retiree
Signature of Domestic Partner
_____/_____/__________
_____/_____/__________
Date
Date
Notary Public Validation
State of Maryland Employee/Retiree
Domestic Partner
Date of Birth: _____/_____/__________
Date of Birth: _____/_____/__________
STATE OF MARYLAND
)
STATE OF MARYLAND
)
COUNTY OF _________________________
)
COUNTY OF _________________________
)
Before me, the undersigned Notary Public, personally appeared
Before me, the undersigned Notary Public, personally appeared
__________________________________________ (Name of State of
__________________________________________ (Name of Domestic
Maryland employee/retiree), who acknowledged the execution of the
Partner), who acknowledged the execution of the foregoing Affidavit of
foregoing Affidavit of Domestic Partnership and swore to the truth of the
Domestic Partnership and swore to the truth of the statements made
statements made therein.
therein.
Witness my hand and Notary Seal this ____day of ____, 20____.
Witness my hand and Notary Seal this ____day of ____, 20____.
______________________________
______________________________
Notary Public Signature
Notary Public Signature
______________________________
______________________________
Notary Public Printed Name
Notary Public Printed Name
My Commission Expires:
My Commission Expires:
_____/_____/_______
_____/_____/_______
County of Residence:
County of Residence:
__________________
__________________

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